CPA CERTIFICATE CANCELLATION STIPULATION AND ORDER

ARIZONA STATE BOARD OF ACCOUNTANCY

100 N. 15th Avenue, Suite 165 Phoenix, Arizona 85007

Phone: 602-364-0804 Fax: 602-364-0903

Email: info@azaccountancy.gov www.azaccountancy.gov

Name (Respondent)

Please visit our website's CPA Directory to find your name as registered with the Board and CPA certificate.

Cert #

The Arizona State Board of Accountancy (Board) and the above referenced Respondent hereby stipulate and

agree that:

1. This matter is within the jurisdiction of the Board pursuant to A.R.S. § 32-701, et seq. and A.A.C.

R4-1-101, et seq.

2. Respondent is the holder of the above referenced Certified Public Accountant Certificate issued by

the Board.

3. A registrant who does not want to renew pursuant to A.R.S. § 32-730(A), nor place the certificate on

inactive status pursuant to A.R.S. § 32-730.01, or a registrant who does not meet the requirements to place

the certificate on retired status pursuant to A.R.S. § 32-730.04, may request that his/her certificate be

cancelled pursuant to A.R.S. § 32-730.02(A), provided that the registrant is not under a disciplinary order by

the Board, except for suspension for non-registration pursuant to A.R.S. § 32-741.01, or that disciplinary

proceedings have not been initiated against the Respondent.

4. Respondent consents to the Board to enter this Stipulation and Order to cancel his/her certificate.

Cancellation of the certificate does not constitute disciplinary action by the Board.

5. Respondent understands the right to consult legal counsel prior to entering into this Stipulation and

Order, and such consultation has either been obtained, or is waived.

6. Respondent understands that this Stipulation and Order is effective upon its acceptance by the

Board, as evidenced by the respective signatures thereto. If this Stipulation and Order is signed on different

dates, the later date shall be the effective date.

7. Once accepted by the Board, this Stipulation and Order and any documents related to it will be a

matter of public record.

ORDER

Based on the above stipulation, the Board hereby issues the following Order:

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Revision Date – November 28, 2018 Page 1 of 2

IT IS ORDERED that, by the request of the Respondent, and in accordance with A.R.S. § 32-730.02, the

Respondent's certificate is hereby CANCELLED. Following cancellation, if the Respondent wishes to reinstate the

CPA certificate with the Board, the Respondent must first meet the requirements of A.R.S. § 32-732(B).

IT IS FURTHER ORDERED that, pursuant to A.R.S. § 32-747, respondent shall not assume or use the CPA

designation, unless the Respondent qualifies for the limited reciprocity privilege, pursuant to A.R.S. § 32-725.

This Order is effective upon its acceptance by the Respondent, and by either the Board or its Executive

Director, through the Board's delegated authority, pursuant to A.R.S. § 32-703(14)(e), as evidenced by the

respective signatures thereto. If Respondent and the Board execute the document on different dates, the later

date shall be the effective date. The parties may execute this Order in counterparts, and the parties understand

and agree that copies of this Order, including facsimile or e-mail signatures thereto, shall have the same force

and effect as originals.

- FORM SUBMITTALS - Submit either by mail, email, or fax.

Email: info@azaccountancy.gov•Fax: 602-364-0903•Phoenix, AZ 85007•100 N. 15th Avenue, Suite 165

Please indicate the mailing address to which the final executed Order is to be sent, and sign and date below.

Address

City State Zip

If you have a CPA firm registered with the Board as a sole owner of a partnership, PC, PLLC, LLC, or LLP; a sole proprietorship; or as an individual CPA; upon the approval of the cancellation of your certificate,

your CPA firm will no longer meet the qualifications to remain as a firm. If the CPA firm is not cancelled, it will be revoked by the Board pursuant to A.R.S. § 32-742.

Signature (Respondent) Date

Signature (Board) Date

Giselle C. Alexander Board President

- or - Monica L. PetersenExecutive Director

Revision Date – November 28, 2018 Page 2 of 2